Trinity Grove
631 Junction Creek Drive
Wilmington, NC, 28412
9104423000
CCN: 345554
3
Overall2
Health5
Staffing3
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| LUTHERAN SERVICES FOR THE AGING, INC. | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| SMITH, KESHA | CORPORATE DIRECTOR | NOT APPLICABLE |
| NICKERSON, KIRBY | CORPORATE OFFICER | NOT APPLICABLE |
| MADDRY, KAREN | CORPORATE OFFICER | NOT APPLICABLE |
| GOINS, TED | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| PARRISH, JAMES | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| SMITH, KESHA | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| SUTTON-SURAK, AUDREY | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LUTHERAN HOME WILMINGTON PROPERTY, INC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LSA MANAGEMENT, INC. | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| LUTHERAN SERVICES FOR THE AGING, INC. | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Penalties (3)
| Date | Type | Amount |
|---|---|---|
| 2025-09-18 | Fine | $100K |
| 2024-10-10 | Fine | $21K |
| 2024-08-05 | Fine | $9K |
Health Deficiencies (16)
2025-09-18 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
C
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
G
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
B
F585 · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
E
F565 · Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
2024-10-10 · Health
D
F810 · Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
G
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2024-08-05 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
K
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
K
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2023-07-13 · Health
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F811 · Nutrition and Dietary Deficiencies
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2023-05-09 · Health
E
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
4.36
RN Hrs/Resident/Day0.54
0.96
LPN Hrs/Resident/Day0.81
0.70
CNA Hrs/Resident/Day2.33
2.69
PT Hrs/Resident/Day0.12
0.08
Data as of 2026-03-01